Versatile Use of V-Y Advancement Flap for Facial Defect Reconstruction: A Case Series in Asian Patients

BACKGROUND

V-Y advancement flap (VYAF) is a commonly used flap for facial reconstruction, but it is not popular in Asian society with limited aesthetic outcome evaluation.

OBJECTIVE

To demonstrate our experience of facial VYAF with the quantitative aesthetic outcome assessment.

METHODS AND MATERIALS

From January 2013 to December 2022, patients who underwent facial VYAF reconstruction were reviewed. Postoperative photographs were collected and independently graded by three plastic surgeons, three nurses, and six non-medical personnel using Manchester scar scale (MSS). The representative preoperative images were selected for surgeons' reconstruction preferences survey.

RESULTS

Forty-eight patients (27 females and 21 males), with a mean age of 66.8 (23-97) years, were included in this study. All flaps survived with no flap necrosis. Only six patients (12.5%) developed minor postoperative complications, and they were treated conservatively and resolved uneventfully. The total MSS score was 7.8 ± 1.9 (scale of 4 [best scar] to 24 [worst scar]) and the overall scar VAS rating was 1.9 ± 1.1 (0 [best scar] to 10 [worst scar]), indicating satisfactory postoperative scar condition. From the survey of 22 plastic surgeons and 11 scenarios, VYAF was rarely chosen among other local flaps which only accounted for 8.7%.

CONCLUSION

VYAF is an easy and safe method for facial reconstruction with low morbidity, but its usefulness is underappreciated. With a proper design and cautious dissection, we believe that good aesthetic and functional outcomes can be achieved with VYAF.

LEVEL OF EVIDENCE IV

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Simple lip reconstruction technique for middle-sized defects in lower lip cancer - Bilateral oblique mucosal V-Y advancement flap

There is no standardized technique for lip reconstruction because the structure and functions of the lip are diverse. We developed a new lip reconstructive approach using a bilateral oblique mucosal V-Y advancement flap. We present the case of a 76-year-old woman with severe dementia, referred to our institute for a tumor on her lower lip. She was diagnosed with lip squamous cell carcinoma (cT2N0M0). The tumor measured 25 × 20 mm. It was resected with a surgical safety margin of 6 mm. Bilateral triangular flaps were fashioned obliquely on the rear lateral side of the defect extending from the labial to the buccal mucosa and used to repair the defect. The operation time was 66 min. She was discharged on the fourth postoperative day without any complications. Speech and food intake functions have been preserved and she has been followed up for 26 months with no recurrence. The lip closing and color match has been adequate despite a slight thinning of the lip. This technique offered a major benefit of short operation and hospitalization time because it was a simple, less-invasive, one-step procedure. This is a practical procedure, suitable for vulnerable patients of advanced age or with comorbidities.

Management of deep sacral and ischial pressure injuries with free-style local perforator flaps: A D+P+DPD model

BACKGROUND

Previous reports on the treatment of sacral and ischial pressure injuries have not provided clear algorithms for surgical therapies. The objective of this study was to establish a reconstruction algorithm to guide the selection of an ideal free-style perforator flap that can be tailored to the defect in question.

METHODS

We used 23 perforator flaps to reconstruct 14 sacral and 8 ischial defects in 22 patients over 5 years. A reconstruction algorithm system was developed based on the anatomical features of the perforator vessels (diameter, D; pulsatility [++∼+++], P) and their position in the skin island (DPD) (ie, D+P+DPD). A perforator-based propeller flap was applied as the first-line choice; if this plan was not feasible, we applied an altered V-Y advancement model or another second-choice technique.

RESULTS

All flaps survived, and only 1 patient experienced partial wound dehiscence, which healed by secondary intention. After an average follow-up period of 11.2 months, no patient experienced recurrence or infection.

CONCLUSIONS

Free-style perforator flap selection is determined by pressure injury and the desired advantage of a specific approach. The use of free-style perforator-based propeller flaps allows a surgeon to transfer healthy tissue into the defect, shifts the suture line away from the bony prominence, and preserves additional future donor sites. In cases where unexpected variations are encountered, the V-Y advancement model or another technique can be used. The simplified surgical algorithm (D+P+DPD) can provide versatility and reliability, achieve a durable, natural esthetic outcome, and minimize injuries to future donor sites.

V-Y advancement flap to correct a perineal defect after an episiotomy dehiscence

INTRODUCTION AND HYPOTHESIS

Episiotomy scar may be the site of complications and result in wound dehiscence in the long term. The aim of this video article was to describe the surgical steps required to repair a right perineal defect after episiotomy using a V-Y advancement flap.

METHOD

Our patient had an episiotomy dehiscence that had already benefited from an end-to-end repair, but the perineal defect recurred. A V-Y advancement flap was performed. The first step of this surgery was to remove the episiotomy scar. A V-shaped flap was then created to fill the perineal defect. Upon advancement, the V flap was transformed in a Y shape and secured using tension-free absorbable sutures.

CONCLUSION

There was no flap necrosis, and the esthetic result was satisfactory.

[Application of modified V-Y advancement flap for reconstruction of facial defect]

Objective:To investigate the clinical effect of modified V-Y advancement flap for reconstruction of facial skin defect. Methods:Thirty-eight patients with facial skin tumors underwent individual tumor resection according to pathological type and lesion depth. Based on the defect site and size, appropriate V-Y advancement flap was designed to reconstruct the skin defect in one stage. There were 9 cases of classic subcutaneous tissue pedicle V-Y advancement flap, 24 cases of modified subcutaneous tissue pedicle V-Y advancement flap and 5 cases of perforated V-Y advancement flap in our study. Results:Among the 38 patients, 34 cases had primary healing. Two cases developed necrosis at the edge of the flap and healed after debridement. Local infection occurred in 2 cases, which healed after short-term dressing change. Postoperative mild eyelid ectropion occurred in 2 cases and oral horn displacement in 1 case. The patients were followed up for 6-36 months postoperatively, and the function and appearance recovered well. One case had local recurrence and 3 cases had parotid lymph node metastasis, which were removed again and supplemented with radiotherapy. Conclusion:The improved design of V-Y advancement flap can enlarge the scope of facial defect reconstruction, and achieve good appearance and function.

The gluteus maximus V-Y advancement flap for reconstruction of extensive soft tissue loss following an advanced sacral pressure ulcer. A case report and mini review

BACKGROUND

The occurrence of pressure injuries (PIs) in an inpatient is a serious medical condition that requires a rigorous clinical evaluation. Management of these lesions should be comprehensive, including general measures and local care. Wound care occupies a large part of the treatment. For large skin loss, the treatment requires plastic surgery techniques for reconstruction. Myocutaneous advancement flaps are a good therapeutic option due to the provision of vascularized tissue within the skin defect. To ensure the success of the surgery, a good surgical technique preceeded by careful preparation of the patient in conjunction with the anesthesia team is imperative.

CASE PRESENTATION

We report the case of a 60-year-old bed ridden man for more than two months following an ischemic stroke with left spastic hemiplegia and loss of sensitivity. He was transferred to our surgical unit for the management of a chronic stage 4 PIs in the sacral area complicated with cellulitis, subcutaneous abscess and severe sepsis. Initial management consisted of resuscitation measures combining fluid therapy, antibiotic therapy, analgesics, blood transfusion, nutritional support, physioteherapy, wound care as well as preventive measures and psychological support. Once the granulation tissues were fully developed, the patient underwent reconstruction surgery with a V-Y myocutaneous advancement flap. The graft was successful with complete wound healing thereafter.

CONCLUSION

PIs are a multifactorial, complex and disabling pathology that requires multidisciplinary care. Surgeons, anesthetists, nutritionists, physiotherapists, nurses must act in agreement in order to provide optimal treatment. Prevention is the rule.

Repair of cutaneous and mucosal upper lip defects using double V-Y advancement flaps

BACKGROUND

The repair and reconstruction of the upper lip defects should focus on the important anatomical landmarks of the upper lip. In this investigation, double V-Y advancement flaps were used to simultaneously repair the cutaneous and mucosal defects of the upper lip. It was especially suitable for young patients with tight skin and high-risk scar hyperplasia in the donor sites.

OBJECTIVE

The objective was to examine the surgical outcomes following the simultaneous repairation of upper lip mucocutaneous defects using double V-Y advancement flaps.

METHODS

A retrospective review of all patients with defects near the vermilion border who underwent double V-Y flaps repair from July 2014 to November 2018 was performed. Transverse V-Y advancement flaps were used to repair the cutaneous defects and longitudinal V-Y advancement flaps to repair the mucosal defects.

RESULTS

Fifteen patients (six males, nine females) were retrospectively reviewed. Defects spanning the vermilion border ranged from 0.8 × 0.5 to 2.5 × 1.5 cm² . Follow-up was for 3 months or longer. There were no perioperative complications or visible postoperative scars, and major anatomic landmarks were preserved and reconstructed. All patients were satisfied with the aesthetic outcome.

CONCLUSION

Double V-Y advancement flaps are suitable for the repair of superficial mucocutaneous defects smaller than 50% of the lateral upper lip, especially for younger patients with tight skin.

Numerical analysis of the V-Y shaped advancement flap

The V-Y advancement flap is a usual technique for the closure of skin defects. A triangular flap is incised adjacent to a skin defect of rectangular shape. As the flap is advanced to close the initial defect, two smaller defects in the shape of a parallelogram are formed with respect to a reflection symmetry. The height of the defects depends on the apex angle of the flap and the closure efforts are related to the defects height. Andrades et al. 2005 have performed a geometrical analysis of the V-Y flap technique in order to reach a compromise between the flap size and the defects width. However, the geometrical approach does not consider the mechanical properties of the skin. The present analysis based on the finite element method is proposed as a complement to the geometrical one. This analysis aims to highlight the major role of the skin elasticity for a full analysis of the V-Y advancement flap. Furthermore, the study of this technique shows that closing at the flap apex seems mechanically the most interesting step. Thus different strategies of defect closure at the flap apex stemming from surgeon's know-how have been tested by numerical simulations.

Salvage total pelvic exenteration with bilateral v-y advancement flap reconstruction for locally recurrent rectal cancer

Total pelvic exenteration for locally recurrent rectal cancer typically requires extensive excision of the pelvic floor with perineal skin. Due to the extensiveness of the procedure and its non-curative nature, it is controversial as purely palliative therapy. A 66-year-old male patient who had undergone abdominoperineal resection at another hospital 8 years prior was admitted to our hospital. During radiation and chemotherapy for 2 years, he complained of perineal pain, discharge, cacosmia and bleeding from a recurrent tumor. The 10 × 8 cm recurrent tumor was exposed on the perineum and the patient suffered from serious discomfort in his daily life during walking or sitting. We performed total pelvic exenteration with partial sacrectomy, after which the large perineal defect was reconstructed with a bilateral V-Y gluteus maximus advancement flap in approximately 120 min. The patient's postoperative course was satisfactory and his quality of life markedly improved.

V-y advancement flap technique in resurfacing postexcisional defect in cases with pilonidal sinus disease-study of 25 cases

We report our experience of technique of V-Y-plasty in treatment of pilonidal sinus. A retrospective study of 25 patients performed from 2005 to 2010 at Deenanath Mangeshkar Hospital and Sassoon General Hospitals, Pune, was performed. The unilateral or bilateral V-Y advancement flap technique was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and recurrence. The follow-up ranged from 6 months to 5 years. The study included 25 cases of pilonidal sinus. Nineteen patients (76%) underwent unilateral V-Y-plasty and six patients (24%) underwent bilateral V-Y-plasty. Eighty-four percent cases were from the age group of 21-30 years. Sixty-eight percent patients were mobilized on the fourth postoperative day and 32% patients were mobilized on the third postoperative day. No recurrence was found in any of the patients. Itching and hypertrophic scar were found in two cases (8%), and decreased sensation was found in one patient (4%). The V-Y advancement flap technique for the treatment of pilonidal sinus is efficient and can reduce recurrence. Unilateral/bilateral V-Y flap achieves suture line away from midline, obliteration of natal fold and coverage of defect without tension. In follow-up none of the patients showed recurrence. This technique has distinctly less morbidity and avoids of multiple dressings, reducing the total cost of the treatment. V-Y advancement flap is distinctly better choice among the available flaps as it is less time-consuming, requires less technical expertise as compared to Z-plasty and perforator flaps, and is reliable and easy to plan.

Giant anorectal condyloma acuminatum of buschke-lowenstein: successful plastic reconstruction with bilateral gluteal musculocutaneous v-y advancement flap

A 58-year-old male patient presented with an anorectal verrucous carcinoma, also known as Buschke-Lowenstein tumor. Clinically, the lesion of the patient best resembled giant condyloma acuminatum with a cauliflower-like appearance. The diagnosis was confirmed with biopsy and an abdominoperineal resection was performed. The perineal defect was reconstructed with bilateral gluteal musculocutaneous V-Y advancement flap. Both functional and cosmetic results 6 years after the operation were excellent. To date, no recurrence has been noted. As long as one is aware of its existence and of its characteristic appearances, the Buschke-Lowenstein tumor is fairly easily diagnosed. The treatment of choice remains surgical resection, and adequate follow-up is essential.